Tag Archives: EAST 2011

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EAST Guidelines Update: Spleen Injury

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The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for spleen injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:

Level I recommendations (best quality data): 

  • none

Level II recommendations (good data):

  • Initial management of hemodynamically stable patients should be nonoperative
  • Unstable patients should undergo immediate operation or angiographic embolization (my interpretation: unstable patients belong in the OR, not the angio suite!)
  • Patients with peritonitis should go to the operating room
  • Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
  • CT of the abdomen with IV contrast is the most reliable method to assess severity of spleen injury (my interpretation: in the hemodynamically stable patient)
  • Angiography with embolization should be considered if a contrast blush is seen on CT, AAST grade > 3, moderate hemoperitoneum is present, or there is evidence of ongoing bleeding
  • Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed

Level III recommendations (weak data):

  • Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
  • Contrast blush is not an absolute indication for operation or angio-embolization. Age, grade of injury and presence of hypotension need to be considered. (My interpretation: don’t operate or do angio on kids without a really good reason)
  • Angio is an adjunct to nonop management in patients who are at high risk for delayed bleeding or to look for vascular injuries (pseudoaneurysms) that may lead to rupture or delayed hemorrhage

Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.

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EAST Guidelines Update: Liver Injury

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The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for liver injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:

Level I recommendations (best quality data): 

  • none

Level II recommendations (good data):

  • Initial management of hemodynamically stable patients should be nonoperative
  • CT of the abdomen with IV contrast is the most reliable method to assess severity of liver injury in the hemodynamically stable patient
  • Unstable patients should undergo operative or endovascular management of their injury, not imaging
  • Patients with peritonitis should go to the operating room
  • Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
  • Angiography with embolization should be considered if a contrast blush is seen on CT
  • Angiography with embolization may also be considered if there is evidence of ongoing blood loss without blush on CT
  • Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed

Level III recommendations (weak data):

  • Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
  • Interventional modalities may be used to treat complications (ERCP, percutaneous drainage, laparoscopy, etc)
  • If a patient transiently responds to fluid initially, try angiography with embolization while they are still stable

On Monday, I’ll present the updated guidelines for management of spleen injury.

Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.

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EAST Evidence Based Review: Distracted Driving

EAST is branching out from one of its core areas, creating trauma practice guidelines. They are now beginning to address other problems using the same techniques for developing their practice guidelines. Instead of generating guidelines for clinical care, they are creating action statements based on the best available literature.

This Distracted Driving review was one of a group of new EBRs was presented last week at the EAST Annual Scientific Assembly. The panel reviewed information from government agencies and studies based on crash databases and simulations. The number of cellphone subscribers has surpassed 250 million, and the number of deaths from distracted driving has followed a similar curve. 

Distracted driving is implicated in 20% of injury crashes and 16% of fatal crashes. Drivers under age 20 has the highest proportion of distracted drivers. 

EAST made three Level II recommendations, which means that they are reasonably justifiable by available scientific evidence and strongly supported by expert opinion. They are:

  • Drivers should minimize all distractions while on the road
  • Cell phone use and texting should not be performed while driving
  • Younger inexperienced drivers should not use cell phones during their probation period (if such a period is mandated by their state)

Future areas of interest will include studying the impact of legislation regarding cell phones and texting, development of crash avoidance systems, and evolving cell phone technologies.

Reference: Evidence Based Review on Distracted Driving, presented at the 2011 EAST Annual Scientific Assembly. Note: this information is preliminary and may be changed prior to publication.

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Distracting Injury and Cervical Spine Clearance

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One of the tenets of clinical c-spine clearance is that there be no “distracting injury.” What does this mean exactly? Can the clinician adequately judge which injuries are too distracting?

The Loyola group prospectively looked at 160 patients needing c-spine clearance over a 9 month period. GCS had to be 14 or 15, and the patients were excluded if they were intoxicated or received an analgesic prior to the clearance attempt. A total of 84% had no neck pain, and 82% of those had no peripheral, potentially distracting pain. Patients with perceived distracting pain and those without had very similar Visual Analog Scores (VAS) for pain. 

Overall, the majority of patients and physicians did not believe that distracting pain was present, and when pain was present there was little agreement whether it was distracting. The few patients who did have spine fractures had a VAS for pain >5. The use of physician judgment for distracting pain and clearance worked just fine in this study.

Bottom line: The authors recommend using clinician judgment as to the degree of distracting pain when clearing the c-spine. If you want to be more objective, if the patient complains of a Visual Analog Score for pain of more than 5, then you may want to delay clearance. Note: this is a small study that really needs to be replicated before widespread use.

Reference: C-spine clearance: don’t be distracted – just trust your judgment. Presented at the 24th annual scientific assembly of EAST, Session II, Paper 9. Click here to see the abstract.